Position Overview
The Risk Management Nurse is responsible for reducing unnecessary or excessive utilization of healthcare services by members identified as high utilizers through claims analysis. The role focuses on proactively reaching out to members and providers displaying statistical deviations from the norm in terms of utilisation. Through clinical discussions, the nurse must gain insights into the reasons for high utilisation and implement recommendations to mitigate such occurrences. The role also involves supporting fraud, waste, and abuse (FWA) investigations, and managing GP authorization processes.
1.Reporting Structure
Line function
- The Risk Management Nurse reports to the Team Leader: Clinical Risk Management within the Provider Networks Team.
Staff function
The Risk Management Nurse has a staff function relationship with the following positions:
- Disease Management Department
- Medical advisors
- Medicine Management Department
- Client services staff
- Administrative staff
- Hospital Utilisation Management staff
- FWA Committee
2.Duties and responsibilities
Outbound calls - Manage Member High utilisation
- Establish or verify if the claims data is a true reflection of the member’s health seeking behaviour
- Establish the reasons for the high utilisation by contacting the members / employees
- Identify actions that can be taken by the member to reduce unnecessary utilisation
- Educate the member on possible ways to meet their medical needs and reduce the high utilisation behaviour
- Explain any limits that apply to the number of consultations that a member is entitled to and processes to be followed after such limits are reached
- If necessary, contact the member’s treating doctor to discuss any concerns
- Refer complex clinical cases to the medical advisor, DUR pharmacist or Disease Management nurse for further intervention or support
- Provide clinical motivation to fund managers where necessary
- Contact members to confirm services rendered as part of FWA investigations
Inbound calls - Manage Member GP consultation
- Authorise GP Authorisation request and Out of Network request subject to clinical guideline protocols and Medical Aid Fund rules.
- Validating member and dependent status.
- Ensuring Member is allocated to a Network GP Provider.
- Confirming member has available visits before loading additional visit.
- Ensure that all telephone and logging systems are logged into 10 minutes before start of shift.
- Answer all telephone calls and ensure that lost/ abandoned calls are limited to the required service level agreements( SLA) of all schemes.
- Answer all incoming calls within 20 seconds
- Adhere to all call centre policies and procedures
- Proactively identify and report any potential escalations and issues to the Team Leader and/or Senior Manager as appropriate
- Keep up to date with policy and product changes.
Required profile for job ad : Clinical Risk Management Nurse - Windhoek
3.Experience and qualifications required
- Enrolled or Registered Nurse
- At least 3-5 years’ experience and knowledge of the medical scheme environment or
- Experience and knowledge doctors’ surgery
- Experience in risk management in a medical scheme environment an advantage
- Experience and knowledge of Network options or Risk Transfer arrangements an advantage
- Excellent communication skills – written and oral
- Ability to deal professionally with conflict situations or difficult people (members and/or providers).
- Familiarity with telephone techniques and skills
- The ability to utilise a computer and keyboard efficiently and accurately.
- Customer service focused.
4.Language requirements
- Be able to speak, write, read and comprehend fluently in English.
- Other languages: The ability to converse in a local ethnic language e.g. Oshiwambo an advantage. The ability to converse in Afrikaans an advantage.
5.Computer literacy
Proficiency in the following programmes is required:
- MS Excel
- MS Word
- MS Outlook/ email
- Ms Explorer/Internet
6.Work requirements
- The company is based in Namibia, Windhoek.
- The hours of work: Office hours from Mon to Fri, 8am to 5pm.
- Confidentiality of all patients’ clinical information and conditions to be maintained and respected. The employee may be required to sign a confidentiality agreement.
- Company intellectual property and systems are not disclosed to external agent or organization.
7.Registration requirements
- Must have a valid registration with the applicable Health Professions Council of Namibia.
8.Remuneration
A competitive salary and benefits will be negotiated, consistent with experience and the role and responsibilities of the position.
